Pancreatic cancer is an aggressive, solid tumor, with a grave prognosis. Despite surgical treatment in patients with pancreatic cancer, the rate of recurrence is high. In addition, although tumor biomarkers are frequently used to confirm advanced pancreatic cancer, this is not accurate and the biomarkers currently used cannot indicate prognosis. This study sought to evaluate circulating tumor DNA as a tumor biomarker to prognosticate pancreatic cancer. Patients with advanced pancreatic cancer and liver metastasis (N = 104) were included, and blood samples were collected from all patients. The mutant allele frequency was measured using amplicon-based deep sequencing on a cell-free DNA panel covering 14 genes with > 240 hot spots. In patients with advanced pancreatic cancer, 50% (N = 52) had detectable ctDNA levels, with TP53 (45%, N = 47) and KRAS (42.3%, N = 44) mutations the most common. Patients with detectable circulating tumor DNA levels also had significantly worse overall survival and progression free survival than ctDNA negative patients (8.4 vs 16 months, P<0.0001 for overall survival; 3.2 vs 7.9 months, P<0.0001 for progression-free survival). In a multivariate analysis, ctDNA status was independently associated with overall survival and progression-free survival (HR = 3.1, 95%CI = 1.9-5.0, P<0.0001; HR 2.6, 95%CI = 1.7-4.0, P<0.0001, respectively). Moreover, circulating tumor DNA significantly correlated with a higher number of liver metastases, the presence of lung and/or peritoneal metastases, tumor burden, and higher carbohydrate antigen 19-9 levels. This study supports the use of circulating tumor DNA as an independent prognostic marker for advanced pancreatic cancer.
Background Atezolizumab plus bevacizumab therapy was recently introduced as the first line for unresectable advanced hepatocellular carcinoma (HCC), but immune-related adverse events (IrAEs) due to atezolizumab are a great concern. Here, we report the case of a patient who developed fatal acquired coagulation factor deficiency after hepatectomy for HCC, treated with atezolizumab and bevacizumab before surgery. Case presentation A 70-year-old man received right trisegmentectomy of the liver with hepaticojejunostomy for advanced HCC with bile duct invasion, after atezolizumab and bevacizumab therapy. The patient suffered the sudden onset of severe multiple coagulation factor deficiency (II, V, VII, VIII, IX, X, XI and XII) immediately following reoperation for anastomotic leakage of hepaticojejunostomy, 7 days after hepatectomy. The coagulation factor deficiency did not reverse even with intensive treatment, and the patient died of uncontrollable bleeding 32 days after hepatectomy. An IrAE due to atezolizumab was suspected because the patient had developed the possible IrAE of enthesitis of the right gastrocnemius muscle before surgery, and specific inhibitors against factor V and anti-factor V autoantibodies were detected, leading to an ultimate diagnosis of autoimmune FV/5 deficiency (AiF5D). Conclusion Severe acquired coagulopathy should be recognized as a possible life-threatening IrAE when using atezolizumab and bevacizumab for HCC.
Pancreas preserving total duodenectomy (PPTD) is rarely performed in patients with duodenal disease. In addition, because PPTD was performed in the past by opening the entire abdomen, case reports of laparoscopic-assisted PPTD (LAPPTD) in patients with duodenal disease are rarer still. Here, we report the case of a 64-year-old man with diabetes in whom abnormal duodenal mucosa was found on endoscopy. The lesion was located close to Vater's papilla, making endoscopic excision difficult; therefore, we planned a surgical duodenectomy. Since imaging findings indicated the lesion to be benign or a non-invasive carcinoma, and the patient had diabetes, we decided to perform PPTD. Additionally, to reduce operative stress, we opted for LAPPTD. Due to excess visceral fat, the surgical time was 11 h 10 min. He had a postoperative course without severe complications, and was followed up for 2 years 6 months, during which he had no relapse or severe complications. We consider this operative method to be admissible in cases of benign or non-invasive duodenal cancer in which pancreas preservation is desirable.
Background: Pancreatic cancer has a grave prognosis. Most patients with metastatic pancreatic cancer are inoperable, and case reports of resection of lung metastasis from pancreatic cancer are rare. This patient underwent resection of a lung metastasis twice after pancreaticoduodenectomy for pancreatic cancer. Case presentation: A 75-year-old man with pancreaticoduodenectomy and adjuvant chemotherapy for pancreatic cancer was diagnosed with a lung metastasis 48 months after surgery. Histological findings after thoracoscopic partial resection of the right lung by video-assisted thoracic surgery confirmed the presence of a lung metastasis originating from the pancreatic cancer. The patient refused chemotherapy. A new lung metastasis was detected 84 months following the second surgery (132 months after the pancreaticoduodenectomy). After thoracoscopic partial resection of the left lung by video-assisted thoracic surgery, the histological findings once again confirmed a metastasis that originated from the pancreatic cancer. The patient refused chemotherapy and remained alive and relapse-free after the 10-month follow-up. Conclusion: Detection and resection of an isolated lung metastasis originating from pancreatic cancer may improve prognosis. Careful follow-up may be warranted to identify patients who might benefit from aggressive local treatment of oligometastasic pancreatic cancer.
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